After the shift change, which patient in the emergency department should the nurse prioritize for assessment?
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight.
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools.
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse.
A 50-year-old patient reporting sudden, severe upper back pain.
The Correct Answer is B
Choice A rationale
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight may be experiencing deep vein thrombosis (DVT), a condition that can lead to serious complications such as pulmonary embolism if not treated. However, DVT is not immediately life-threatening in most cases.
Choice B rationale
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools is likely experiencing gastrointestinal bleeding, a common side effect of anticoagulant therapy. This can lead to severe blood loss, anemia, and hypovolemic shock, which can be life-threatening if not promptly addressed. Therefore, this patient should be prioritized for assessment.
Choice C rationale
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse likely has peripheral artery disease and an infection that could lead to sepsis if not treated. However, while this condition needs medical attention, it is not as immediately life-threatening as gastrointestinal bleeding.
Choice D rationale
A 50-year-old patient reporting sudden, severe upper back pain could be experiencing a number of conditions, ranging from musculoskeletal strain to aortic dissection. While an aortic dissection is a medical emergency, without additional symptoms such as chest pain, shortness of breath, or loss of consciousness, this patient is not the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Sexual activity uses about as much energy as climbing two flights of stairs. This comparison can help patients understand that if they can perform activities of similar exertion without chest pain or undue fatigue, it may be safe to resume sexual activity. However, patients should always consult with their healthcare provider before resuming sexual activity after an acute myocardial infarction (AMI).
Choice B rationale
While holding and cuddling are good ways to maintain intimacy after a heart attack, this does not directly address the patient’s question about safely resuming sexual intercourse.
Choice C rationale
While it is true that the doctor will provide sexual guidelines when the patient’s heart is strong enough, this response does not provide the patient with immediate guidance or reassurance.
Choice D rationale
While most patients are able to enjoy intercourse without any complications, this statement may be too general and does not take into account the individual patient’s health status and recovery progress.
Correct Answer is B
Explanation
Choice A rationale
While fasting may be required before certain procedures, it is not the most crucial piece of information that the nurse needs to relay to the healthcare provider prior to a cardiac catheterization and coronary angiogram.
Choice B rationale
A shellfish allergy is crucial information because the dye used in an angiogram can cause an allergic reaction in people who are allergic to shellfish.
Choice C rationale
Although a previous heart attack is significant medical history, it is not the most crucial piece of information to relay prior to this procedure.
Choice D rationale
The rating of the patient’s pedal pulses is not the most crucial piece of information to relay prior to this procedure.
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